IN THIS ISSUE:

Page 3: Addis Ababa University’s School of

Public Health

ADDRESSING ETHIOPIA’S URBAN HEALTH CHALLENGES

Page 4: The promise of an AIDS-free generation Page 2: Deploying 425 UHE-ps: support for pre-

service training

JULY 2015 | VOLUME 1, ISSUE 1

Approximately 18% Ethiopia’s population resides in urban areas. However,

with the current trend of fast urbanization, the Ethiopian urban population is

expected to grow to 35% by 2030, and 42% by 2050. It is undeniable that this

population growth will lead to complex health challenges.

Although access to health care services is currently better in urban areas than

rural areas, multiple factors are challenging equity of access to health

services among urban residents in Ethiopia:

HIV prevalence is more than five times greater among women living in urban and peri-urban centers compared to women living in rural communities;

More than 50 percent of pregnant women in urban centers still deliver at home; and

Despite proximity to facilities, neonatal deaths in urban settings are almost as high as the rate in rural settings.

To be prepared to address the health challenges related to rapid population

growth and urbanization, the Government of Ethiopia initiated the innovative

Urban Health Extension Program in 2009. The program’s aim is to improve

access to and equity of public health information and services for urban

populations by deploying thousands of nurses to serve as community health

workers providing house-to-house health services. In support of the

Government’s program, John Snow, Inc. (JSI), implemented the USAID-

funded Urban Health Extension Program from 2009—2012 in 19 selected

cities across the country. Building on achievements, in 2014, JSI launched a

five-year USAID-funded Strengthening Ethiopia’s Urban Health Program

(SEUHP) that aims to improve quality of community level health services,

enhance access to facility health level health care, and strengthen the

capacity of health systems urban settings.

SEUHP provides comprehensive support to Ethiopia’s Ministry of Health to

strengthen the Government of Ethiopia’s Urban Health Extension Program.

SEUHP works closely with City/Town Health Offices and urban health

extension professionals (UHE-ps) to strengthen capacity through trainings,

coaching, and mentoring. As a result of these efforts, UHE-ps have improved

knowledge and skills on referrals, defaulter tracing, and services data

recording tools and management.

To improve urban health data collection, analysis, and use, SEUHP

developed service data recording and reporting tools for UHE-ps to capture

data on services that they directly provide to beneficiaries as well as data on

referrals they make.

With the aim of increasing demand for facility-level health services among

urban dwellers, SEUHP supports the Government to establish and maintain

strong referral systems that help connect UHE-ps with health centers. SEUHP

has also worked with Regional Health Bureaus and City/Town Health Offices

to standardize referral slips and conduct training on their use.

Environmental health challenges are among the major setbacks to urban

health successes. Diseases associated with inadequate water, sanitation,

and hygiene (WASH) remain among the country’s most serious public health

problems. Diarrhea kills more young people per year than HIV/AIDS, malaria,

and measles combined. Proper use of latrines will decrease the incidence of

diarrheal diseases at large, yet access to land for constructing latrines

among the poor neighborhood remain a challenge. To tackle these

challenges, strong inter-sectoral collaboration among private and public

sector actors is critical. As a step in this direction, SEUHP supports Urban

Sanitation and Waste Management (USWM) forums and regional and city/

town meetings in order to ensure collaborative planning and implementation

of WASH initiatives.

URBAN HEALTH UPDATE

Strengthening Ethiopia’s Urban Health Program (SEUHP) aims to improve the health status of the urban population in Ethiopia by reducing HIV/TB-related maternal, neonatal and child morbidity and mortality, and by reducing the inci-dence of communicable and non-communicable diseases. SEUHP is supported by the U.S. Agency for International Development (USAID). John Snow, Inc. is the prime implementer in close partnership with Federal

Ministry of Health, Regional Health Bureaus and City/Town Health Offices. Addis Ababa University and Emmanuel Development Association are national imple-menting partners. SEUHP works in Addis Ababa, Dire Dawa, Harar, Amhara, Tigiray, Oromia and South People Nations and Nationalities (SNNP).

Supporting hands knocking on every door!

Since 2009, the Government of Ethiopia has implemented the innovative

urban health extension program that aims to bring better health

outcomes to urban communities with urban health extension

professionals (UHE-ps) as its front-line implementers. The work of

UHE-ps centers on households. They also cover schools and youth

centers. Walking around villages, UHE-ps knock on every door with

health information and health services or to refer clients to health centers

as necessary. Currently, one UHE-p is assigned to reach around 500

households. It is not easy for these women to efficiently provide

standardized health promotion and prevention services and to maintain

strong referral linkages with public health facilities; nor to truly support all

500 households in her catchment area. To support them, SEUHP is

implementing various support schemes to capacitate and motivate UHE-

ps and strengthen the system they work in.

SEUHP provides UHE-ps with core public health training on the critical

areas of HIV, maternal, newborn, and child health, reproductive health/

family planning, tuberculosis, and data reporting/recording, among other

topics, to build their capacity to ensuring quality in her services.

Understanding the need for job aids to guide her conversation with

families, SEUHP provides her with on-job-tools. SEUHP also supports

efforts to strengthen documentation and referral systems to promote

health facility use among the community. SEUHP recognizes that the

challenges of UHE-ps are not yet entirely addressed. Attrition rate is high

among UHE-ps, and improvements must be made to keep UHE-ps job

satisfaction and motivation high. Regional and City/Town Health Offices

that manage the urban health extension program and professionals

require support in their planning, supervision, and monitoring and quality

improvement activities. Support in policy and system level improvements

are essential. Hence, SEUHP takes this opportunity to invite all

stakeholders engaged in Ethiopia’s urban health system to support

improvements in urban health through the health system and UHE-ps,

the backbone of the system.

With an attrition rate of approximately 10%, UHE-p turnover is a huge challenge for the UHEP. Regional Health Bureaus responsible for deployments of new UHE-ps often face financial and technical challenges to provide pre-service training. In response, SEUHP collaborated with Regional Health Bureaus across SNNP, Dire Dawa, and Harar to organize pre-service trainings for newly recruited clinical nurses to become UHE-ps. The pre-service training was provided for three months in the health science colleges of respective regions. The primary objective of the pre-service training is to introduce the newly recruited clinical nurses to the Urban Health Extension Program service packages and equip them with required skills in health promotion and disease prevention. According to Tizita Tilahun, 22, who recently participated in an intensive three month pre-service training at Hawassa Health Science College to become a UHE-p, the training helped her significantly in making a shift from clinical orientation to community-based health service provision.

“Previously I had limited knowledge on community-based health services. Now I have acquired adequate knowledge and skills on public health and on the urban health extension packages. The training prepared me well and I am ready to serve my community.”

The pre-service training contributes towards improving the quality of

health services delivered by UHE-ps by creating balance in the proportion

of households one UHE-p should cover. Currently, a UHE-p is expected to

provide comprehensive community level health services to 500 households in

her catchment area.

EDITORIAL

Pre-service Training Prepares 425 UHE-ps in

SNNP, Dire Dawa, and Harar

UPDATES

Tizita Tilahun recently received a three month pre-service training in

Hawassa Health Science College and formally became a UHE-p.

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Strengthening Ethiopia's Urban Health Program (SEUHP) is happy to issue its first-ever newsletter that aims to

document and disseminate leading practices and policy development in the Ethiopian Urban Health Program. We

devote this publication to engaging stakeholders in our journey to strengthen the country’s urban health system.

ADDIS ABABA UNIVERSITY

Partner in Research and Urban Health Development Hub

SEUHP commissioned three situational assessments to improve understanding of urban health dynamics in Ethiopia. The three assessments focused on human resource management, urban sanitation and waste management (USWM), and behavior change communication (BCC). The BCC formative assessment assessed knowledge of and attitudes toward health care services and the current knowledge, attitudes, and practices in utilizing health care services. Barriers and motivators to health service utilization, exposure to the UHEP, and sources of information for BCC were explored. The study results indicate that the strategy for reaching communities through UHE-ps at the community level needs tailored messaging and approaches for demand creation in use of health facilities. The HRM assessment explores the core functions, best practices, challenges, and gaps of HRM for UHE-ps and their supervisors, and provides recommendations to prioritize improvements.

The study identified the absence of standards throughout the HRM system across the country as the major challenge in HRM of urban health. Problems related to work environment and conditions, retention mechanisms, and performance appraisals also found to be contributing for the high UHE-p attrition rate. The USWM assessment provides insights on current attitudes, knowledge, and practices related to USWM. Overall, the study illustrates that the the USWM situation is grossly poor, characterized by poor linkages between policies/strategies and operational practices. Urban communities’ knowledge and attitudes on waste management, hand hygiene, safe handling of drinking water, and prevention of diarrhea were identified as generally low. Solid waste management is also inadequate to satisfy the growing needs of urbanization. Access to protected drinking water was found to be relatively better than other sanitation practices.

As part of SEUHP, JSI has established a strategic partnership with Ethiopia’s leading academic institution, Addis Ababa University's School of Public Health (AAU/SPH). The partnership was officially launched in Addis Ababa on June 16, 2015 in the presence of the State Minister of Health, His Excellency Dr. Kebede Worku along with representation from USAID, the World Health Organization, Addis Ababa City Administration, other line ministries, and SEUHP/JSI staff. This partnership will ultimately establish a center of excellence for urban health programming, which will promote innovation, program implementation, and quality improvement. In establishing the center, the partnership will leverage SEUHP's experience in generating evidence and improving quality of the Government of Ethiopia’s Urban Health Extension Program. In his remarks, Dr. Kebede Worku expressed his support for evidence-based planning and implementation and stressed the importance of the partnership between JSI/SEUHP and AAU/SPH in contributing to the improvement of health care services quality and access for Ethiopia’s urban poor.

Alemayehu Gebremariam, JSI Chief of Party, highlighted how the partnership will help generate evidence on key determinants of urban health and will bridge the gaps between research and policy.

GENERATING EVIDENCE FOR URBAN HEALTH

Three Baseline Assessments Conducted

His Excellency Dr. Kebede Worku launches the partnership between

SEUHP and AAU.

MAPPING PUBLIC AND COMMUNAL LATRINES

According to the 2014 Mini Demographic and Health Survey of Ethiopia,33% of Ethiopia’s urban dwellers use shared latrines (communal and public). The fact that most shared latrines are built by a variety of actors (government, nongovernmental organizations, and the community) makes managing the latrines difficult. There is lack of data on the quantity, quality, location, current functionality status, and management practices of public and communal sanitation facilities as there is no responsible regulatory body to manage them. This causes a major challenge in relation to planning and executing activities of improving hygiene and sanitation facilities. In response to this challenge, SEUHP undertook mapping of existing public, communal, institutional, and household latrines, along with water points, using global positioning systems in 28 cities/towns. The data from the mapping will fill gaps related to the lack of up-to-date quantity, quality, location, current functional status, and current management practices of hygiene and sanitation facilities. More importantly, the data will facilitate targeted approaches to improving functionality of hygiene and sanitation facilities.

Maps of public WASH facilities distribution and functionality were

displayed at the National WASH Forum.

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Hidija Ebrahim, 32, is mother of two who lives in Dire Dawa, in Eastern Ethiopia.

Hidija and her husband moved to the urban center two years ago. Soon

after, Hidija became pregnant. Her unfamiliarity to the area coupled with

lack of awareness about health care services limited her from accessing

health care services including testing for HIV. According to the 2014

Ethiopia Mini Demographic and Health Survey, 18% of women residing in

urban areas do not receive antenatal care.

Hilina Abebe is one of the two urban health extension professionals (UHE

-ps) working to provide health education and health care services in

Hidija’s neighborhood (kebele) of 376 households. The kebele is known

for its large concentration of migrants with disposable income, as many

work in construction sites. Through her regular outreach work, Hilina

discovered Hidija during her seventh month of pregnancy, and linked her

to the nearby health facility- Abubekir Health Center. This was first time

Hidija tested for HIV, and she learned that she is HIV positive. In Ethiopia,

there are an estimated 3,886 new infections each year due to mother-to-

child transmission. Timely interventions can reduce the incidence of

mother-to-child transmission.

According to Hilina, tracking and linking the pregnant mother to the health

center is not enough by itself. UHE-p follow-up visits are equally

important to ensure that pregnant women are following-up on antenatal

care and prevention of mother-to-child transmission (PMTCT) of HIV

services properly. “Hidija was in denial about her status. I had to make

frequent visits and provide intensive advice to make sure that Hidija

understood the risks on her passing the virus to her unborn child if she

defaults from PMTCT follow-ups. This is how I helped one child to be

born HIV free,” describes Hilina.

As indicated in the Government of Ethiopia’s 2012 Accelerated Plan for

Scaling Up PMTCT Services in Ethiopia, 60% of women identified as HIV

positive at antenatal care clinics are not provided PMTCT services.

Although UHE-ps identify pregnant women in their catchment areas,

absence of documentation of pregnant women presents a significant

challenge to ensuring access to antenatal care, PMTCT, institutional

delivery, postnatal care, and vaccination for pregnant women and

children under the age of one. This challenge also hinders UHE-ps from

providing consistent follow-up to pregnant women on whether they are

properly following their antenatal care or PMTCT services once they are

linked with health facilities.

In order to address these challenges, SEUHP provides technical support

to UHE-ps in identifying and linking pregnant women to health facilities

for antenatal care and PMTCT services through its supportive supervision

and onsite monitoring and coaching strategy.

SEUHP provides UHE-ps with guidance to keep records of pregnant

women and children under the age of one within their catchment area for

follow-up services. A registration format for pregnant women was

developed in collaboration with respective City/Town Health Offices and

distributed to UHE-ps. According to Hilina, the guidance and techniques

she acquired from supportive supervision sessions have encouraged her

to adequately track and reach mothers in the community. “We [UHE-ps]

are more cautious about our maternal and child health work after it was

communicated to us that we should document every pregnant mother and

child under one in catchment area. I have to track every pregnant mother

as I am expected to update the data every three months.” Currently Hilina

is currently tracking eight mothers who she linked to Abubekir Health

Centre for antenatal care services.

The Program’s initiative to strengthen the linkage between UHE-ps and

health facilities is also enabling UHE-ps to make efficient referrals and

ensure the continuum care for pregnant mothers. The Program produced

a standardized referral tool and offered on-site coaching on proper

utilization of the tool that enables UHE-ps like Hilina to receive feedback

from the health centers that follow-up with mothers.

An urban health extension professional who is supported by Strengthening

Ethiopia’s Urban Health Program with a child born HIV free as a result of her efforts.

SUCCESS STORY The Promise of an AIDS-Free Generation, One Child at a Time

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Strengthening Ethiopia’s Urban Health Program (SEUHP)

Tel: +251 11 4 700402/45, Fax: +251 11 4 700407, Addis Ababa Ethiopia

Disclaimer: This publication was made possible through support provided by the Office of HIV/AIDS, Bureau for Health, U.S. Agency for International Develop-ment, under the terms of USAID/Ethiopia Cooperative Agreement No. AID-663-A-13-00002. The opinions expressed herein are those of John Snow, Inc., and do

not necessarily reflect the views of the U.S. Agency for International Development.